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Dysphagia Evaluation Given the high incidence of dysphagia in infants with VFP, a clinical feeding and swallowing evaluation is recommended before initiating oral feeding. (48) The evaluation should be conducted by a speech-language pathologist (SLP), who is an integral member of the management team for infants with VFP. There are currently no standardized clinical assess ments of feeding and swallowing in the neonatal population; however, there is a consensus of the components that en compass a thorough formal clinical feeding and swallowing evaluation. (48)(49)(50) This includes a medical history, cranial nerve examination, assessment of oral structure and function, assessment of respiratory status, determination of oral feeding readiness, evaluation of non-nutritive and nutritive sucking, and observation of physiologic stability before, during, and after feeding. (48)(49)(50)(51)(52)(53) Though the clinical evaluation provides a wealth of informa tion, an instrumental swallow assessment is crucial to de fi n ing the physiology of the swallow. (50)(51)(54) An instrumental assessment allows for the direct visualization of oral, pharyn geal, and upper esophageal phases of swallowing. This helps to de fi ne the nature and physiology of the impaired swallow, evaluate for aspiration, and determine the ef fi cacy of compen satory strategies. The most widely used instrumental assess ments of swallowing are video fl uoroscopic swallow study (VFSS) and fi beroptic endoscopic evaluation of swallowing (FEES). Both of these instrumental assessments have advan tages and limitations as outlined in Table 3. Bilateral Vocal Fold Paralysis Tracheostomy can be performed to bypass the restricted glottis airway in patients with BVFP. However, tracheos tomy is not universally necessary in neonatal BVFP and has been reported in 54% to 69% of cases. (9)(12)(55)(56)(57)(58) Tracheostomy is more common when other comorbidities are present, such as Arnold-Chiari malformation or other neurologic conditions. In a study of infants with Arnold Chiari malformations and VFP, 86% required tracheos tomy. (59) BVFP that was iatrogenic or neurologic required tracheostomy compared with idiopathic BVFP. (9) Presence of concomitant airway disease also increases the need for tracheostomy. (56) Because tracheostomy is not uniformly required for BVFP, allowing a waiting period of close monitoring is appropriate in most cases. This allows for spontaneous recovery of vocal fold movement and an eval uation of whether the infant can breathe and eat safely despite the BVFP. Tracheostomy can be a permanent MANAGEMENT

measure or a temporary option. Many infants who require tracheostomy for BVFM can undergo decannulation at a later time after either watchful waiting or another surgical intervention. (55)(56)(58) Besides tracheostomy, there are several different laryn geal procedures to manage airway obstruction in patients with BVFP. Endoscopic posterior cricoid split with cartilage grafting (60)(61) and endoscopic anterior and posterior cricoid split with dilation and stenting (62)(63) widen the laryngeal framework. Partial posterior cordotomy, (64)(65) suture lateralization of the vocal fold, (66)(67) and suture lateralization of the arytenoid complex (68)(69) can also be performed to open up the glottic airway. Injection of ona botulinum toxin A directly into the cricothyroid muscle to paralyze this laryngeal adductor has also been shown to resolve stridor and avoid the need for a tracheostomy. (70) These procedures can be performed either in the neonatal period, with the goal of avoiding tracheostomy and main taining a safe airway, or later in childhood for decannulation. Dahl and colleagues achieved decannulation in 28.6% of patients with BVFP, with an endoscopic posterior cricoid split with autologous cartilage grafting. (60) These laryngeal procedures are considered safe and effective in both infancy and childhood. Worsening of swallow function and aspira tion is a concern when opening up the glottis, but that has not been reported as a common problem after these pro cedures. (60)(61)(62)(63)(64)(66)(68)(69)(70) Recovery of vocal fold movement, improvement in associ ated respiratory symptoms, and improvement in dysphagia have been reported after bony decompression of Arnold-Chiari malformations. (6)(59)(71) Jang and colleagues reported that early bony decompression was associated with avoidance of tracheostomy in the majority of patients with Chiari I but not Chiari II malformations. (59) Unilateral Vocal Fold Paralysis Airway interventions such as tracheostomy are rarely re quired for UVFP, unless there is a concomitant secondary airway lesion or neurologic disorder. (9) Infants with UVFP who have respiratory symptoms may improve with side lying with the affected side down. This is attributed to gravity pulling the paralyzed vocal fold away from the mid line to open the glottic airway. (41) In infants with aspiration resulting from a UVFP, early injection laryngoplasty has been advocated, which involves directly injecting a resorbable material into the vocal fold under general anesthesia. Case series have identi fi ed improved oral feeding and no adverse events after injection laryngoplasty in infants. (72)(73) This is the only laryngeal procedure commonly considered in infants with UVFP and

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